Nurses spar with doctors as 30 million insured seek care

Christy Blanco's health clinic in El Paso, Texas, has all the necessary equipment and a waiting list of patients. Yet the clinic sits empty.

Fifty 50 miles away, in Las Cruces, N.M., dozens of nurse practitioners at clinics like Blanco's are busy caring for patients with a range of diseases from diabetes to asthma to depression.

The only difference between the facilities is that in Texas, nurse practitioners are required to have a doctor under contract approve 10 percent of medical charts and spend one of 10 days at the clinic. In New Mexico, no doctor is needed.

"I just want to get started," said Blanco, who has a Ph.D. in nursing and for two years has sought a doctor for her clinic geared for low- income women. "I'm trying to work for the poor. I've spent thousands of dollars of my own money. I have a waiting list of patients, and I have to tell them I can't practice yet."

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Blanco is caught in a tug-of-war between doctors and nurses over who will provide basic primary care for the 30 million U.S. citizens expected to get health insurance under the 2010 health-care law.

Nurse practitioners say they can do their jobs just fine without doctors and they're lobbying lawmakers to end restrictions in more than a dozen of the 34 states that require physician oversight. Despite the need for increased care, doctors are fighting for restrictions with their own lobbying efforts as well as with lawsuits nationwide, arguing that patients' basic care is at risk.

"Doctors are under a lot of pressure financially and feel like they are losing some of their patient volumes and traditional position as captain of the ship," said John Rowe, former chief executive officer of Aetna and of Mount Sinai NYU Health. At the same time, "nurses find it demeaning and unprofessional to be in a situation where they are restricted from doing what they know they can do."

The showdown comes as the United States faces a shortage of more than 13,000 doctors, a gap expected to grow to 130,000 by 2025, according to the Association of American Medical Colleges, a Washington-based nonprofit that represents medical schools. That may leave 7 million Americans living in areas without enough primary care doctors, according to a study last month in the journal Health Affairs.

The American Association of Nurse Practitioners says some of the country's 155,000 nurse practitioners could help fill the need and at a lower cost than doctor-provided care. Insurers typically reimburse them 15 percent less than doctors.

"There just aren't going to be enough health-care providers in the workforce unless we get nurse practitioners out there," said Bobbie Berkowitz, dean of the Columbia University School of Nursing in New York. "They are educated to prescribe and manage disease, and licensed to do that. The restrictions are seen as unnecessary, at best."

A panel of health officials led by University of Miami President Donna Shalala, a former secretary of Health and Human Services, found that state laws limiting nurse practitioners need to be changed so nurses can practice without the oversight of a doctor, according to a 2010 report published by the Institute of Medicine, a division of the National Academy of Sciences. In a 2009 report by the Rand Corp., a Santa Monica, Calif.-based policy institute, researchers found no evidence that nurses provide lower quality care and estimated they could reduce the costs of office visits by as much as 35 percent.

"It is absolutely proven, according to the National Academies, that nurses can provide core primary care services as effectively as physicians," said Rowe, now a professor of health policy at Columbia University in New York.

Under the current system, each state regulates the level of oversight required for nurse practitioners, who are registered nurses that hold either a master's degree or doctorate in nursing. In 16 states, including Colorado, New Hampshire, and Washington, nurse practitioners have full authority to evaluate and diagnose patients, order diagnostic tests and prescribe drugs. That enables them to open a practice or work in a retail clinic with no doctor on staff.

The remaining states have a patch work of legislation with a variety of restrictions and limitations. In Florida and Alabama, for example, nurses can't prescribe certain drugs for pain, insomnia or attention deficit disorder that are considered controlled substances. In New York, nurses need a written collaboration agreement with a doctor and there is a limit on how many nurse practitioners each doctor can work with, creating a cap on nurse practitioners in the state.

Lawmakers in at least 10 states, including New Jersey and Massachusetts, may vote this year on legislation that would allow nurse practitioners to practice independently, according to the American Association of Nurse Practitioners, an Austin, Texas-based advocacy and lobbying group.

Doctors' groups, led by the American Medical Association, say they are ready to fight those efforts and warn the changes could endanger patients and further fragment the health-care system. Removing doctor oversight of nurse practitioners "would seriously endanger the patients for whom they care," Elizabeth Dears, a senior vice president for the Medical Society of the State of New York, an advocacy group for New York doctors, said in testimony to lawmakers. In New York, the governor's proposed budget would allow the health department to remove the need for a written collaboration between a doctor and nurse practitioner for primary care.

"Physicians, physician assistants, nurses and other health-care professionals have long worked together to meet patient needs for a reason: the physician-led team approach to care works," Jeremy Lazarus, president of the American Medical Association, said in a statement.

In Kentucky, doctors pushed for legislation last year that would increase restrictions on nurse practitioners, said Taynin Kopanos, vice president state government affairs for the American Association of Nurse Practitioners. She said she expects similar action again this year. The move came after nurses had advocated for laws that would give them independence from physicians.

After doctors' groups lobbied against legislation in Texas last year to give nurses independence, the state's nurse practitioners group compromised this year on a bill that would lessen restrictions without eliminating them entirely, said Sandy McCoy, president of the Texas Nurse Practitioners.

"We really would have liked independent practice, but we realized we work in a state that has one of the most powerful medical groups in the country," said McCoy who is also clinical director of bariatrics at Baylor University Medical Center. "They have deep pockets and are able to provide more financial contributions than we can and that does have influence to some extent in the legislature."

The Texas Medical Association has given $4.81 million to state legislative candidates and ballot measures since 2003 and the Texas Academy of Family Physicians has contributed $213,500, according to the National Institute of Money in State Politics, a Helena, Montana-based nonprofit that tracks spending in state politics. That compares with $250 in contributions from the Texas Nurse Practitioners and $63,554 from the Texas Nurses Association, according to the group.

Policy briefs by the Texas Academy of Family Physicians contain accounts by doctors of patients misdiagnosed by nurse practitioners, cite studies showing nurse practitioners are more likely to overprescribe drugs such as antibiotics, and highlight the gap in training between doctors and nurses. Dan Finch, legislative affairs director for the Texas Medical Association, said his group is not opposed to lessening restrictions on nurse practitioners as long as there is still doctor involvement and oversight.

In some states, doctors have gone to court to block nurses from expanding their duties. In Iowa, doctors sued the state in 2010 after it began allowing nurses with advanced training to supervise an imaging procedure called fluoroscopy. The doctors said the move put patients at risk because nurses weren't properly trained in the procedure, which exposes patients to radiation. The case is now before the Iowa Supreme Court after a lower court sided with the doctors.

In Colorado, doctors sued the state in 2010 after the governor decided to opt out of a federal law requiring doctor supervision of nurse anesthetists, nurses who specialize in administration of anesthesia, and said the move put patients at risk. A Colorado appeals court sided with the nurses last year.

A similar lawsuit was filed in California where the state Supreme Court said last year it wouldn't review the governor's decision in 2009 to opt-out of the federal requirement, allowing certified nurses to administer anesthesia without doctor supervision.

As the lawsuits and legislative battles drag on, many nurse practitioners are in limbo. Blanco said she has tried with no success to reach a deal with five doctors to partner with them. In some cases, the doctor wanted more money than she was willing to pay. One doctor wanted 25 percent of her revenue, she said. In another case, the doctor didn't want the extra liability.

Blanco said she and another nurse practitioner may move to Albuquerque, N.M., where she's found a spa there that will rent her space for her clinic. As soon as she has registered with the state, she could start seeing patients.

"We need to start paying back our loan. We are spending money and making no profit," she said. "It is a business."